e) FAQs Pathways' Essentials
Service pathways vary from one person with ABI to another. Finding the right pathway for each person is challenging.
The following are essential questions to ask, and have answers for:
1. What is recovery and rehabilitation?
What is recovery?
Becoming well again.
What is rehabilitation?
Rehabilitation aims to facilitate ongoing recovery.
Rehabilitation enables a person to become as independent as they possibly can. The goal is for the person to return to their previous abilities, activities and way of life as much as they possibly can. It means enabling the person to live with their remaining abilities and develop strategies to enable them to compensate and overcome new difficulties.
The process of rehabilitation experienced by each person is unique. Just as a brain injury is unique, the type of rehabilitation program the person is engaged in is uniquely tailored to target individual needs. Rehabilitation addresses specific areas of physical difficulty, thinking or cognitive processing, perception, social skills and relationships. It also addresses broader areas of returning to work, getting about in the community, and adjusting to changes a person may experience following a brain injury.
Rehabilitation goals can build on each other, for example managing transport before getting a job.
Rehabilitation is ongoing.
It may also be episodic - as new situations and opportunities arise.
Rehabilitation is not something that is done to the person, rather with the person.
Rehabilitation is based on working with the person to achieve things that matter to them. Therefore, for it to be successful, the individual needs to participate actively in the rehabilitation process. The type of rehabilitation offered needs to be meaningful and relevant to the person. This means the person, their culture, pre-injury lifestyle, family and environment are critical to ensuring the success of rehabilitation.
The person's abilities will determine how the person is able to participate in the rehabilitation process.
Where recovery to the person's pre-injury life pathway is not possible rehabilitation involves choosing another meaningful but different pathway to a life worth living.
2. Who’s who in the recovery and rehabilitation team? Responsible for?
a) Acute rehabilitation,
b) Post-acute rehabilitation/community re-settlement
c) Social rehabilitation
The rehabilitation team at different stages of recovery and rehabilitation
Working with a person with an acquired brain injury often means being part of a team. It is important to understand everyone's role.
The nature of the team can change over time with the stage of the rehabilitation process:
Stage 1: Acute rehabilitation
This acute stage involves initial management to ensure the person is medically stable in the Intensive Care Unit and high dependency wards. Acute rehabilitation normally occurs within hospital with a strong focus on physical recovery and regaining independent living skills.
The Team: Acute care staff and family and friends
Stage 2: Post-acute rehabilitation/community re-settlement
This stage involves managing the transition from hospital back home, and the ongoing process of rehabilitation that occurs after discharge. The focus of rehabilitation at this stage may include return to work or study, finding alternatives where this is not possible and relearning skills for community living.
The Team: Rehabilitation team
Stage 3: Social rehabilitation
This is the long-term rehabilitation aimed at maintaining and enhancing the level of participation in community life that people with ABI can achieve over their life span (community integration).
The Team: Community living team
The Rehabilitation Team members
In addition to family and friends some of the common roles are:
Residential Care Staff
The rehabilitation team's primary responsibility
The rehabilitation team's primary responsibility is to the individual who has the brain injury.
They are working with this person to achieve his or her goals. The extent the brain injury has limited that person's ability to make informed decisions is determined by the Team through the assessments and observations.
If the Team feels the person is not able to understand the complexities of the information being given in order for a decision to be made, they will approach another who is perceived to make decisions that are in the best interest of the person who has the brain injury. This may be a family member or a close friend. If it appears there is conflict or discrepancies in what different people feel is most appropriate for that person, the rehabilitation team may consider making an application for an independent decision-making body, e.g. the Guardianship Tribunal. A substitute decision-maker may be appointed in areas of accommodation, medical and dental management, finances and service utilisation. If no family person is identified as suitable then a Public Guardian or Estate Manager can be appointed.
3. Who’s who in the recovery and rehabilitation team?
Doctors, clinicians, specialists, social workers, case managers . . .
Members of the rehabilitation team
Person with the ABI
The person with the ABI is the most important member of the Rehabilitation Team
Family members/significant others
The next most important members are family members and significant others.
Here are other possible members of the Rehabilitation Team:
Rehabilitation Specialists (Doctors)
Rehabilitation Doctors monitor and treat medical issues following a person’s injury. They usually start working with the person while they are in the hospital and then provide review after discharge in outpatient clinics.
Involvement includes (but not limited to) medication review, liaison with other doctors (specialists and GPs) organising medical tests and medical clearance (e.g. return to work and driving).
Rehabilitation Assessment (Brain Injury Specific) is usually conducted by a Rehabilitation Physician (usually linked to a BIRU or TLU) to review rehabilitation needs and ability to participate in brain injury specific rehabilitation and review the person's current health status and further health needs that may require intervention.
Nurses work closely with the person with ABI in hospital. They get to know the person very well and often express individual concerns to the rest of the Team. The nurses work to maintain the wellbeing of the person in the hospital setting.
Community nurses generally have specific tasks. For example, changing dressings and giving injections. They liaise with the local doctor.
Services from registered nurses may be required following discharge for some tasks e.g. changing supra pubic catheters (SPC), wound care assessment and treatment. In the community these services are generally available from the local community health centre or from private nursing agencies.
Case Managers develop and oversee the rehabilitation plans and are frequently the primary contact person with whom the individual can raise issues, express concerns and ask questions for further information.
Case Management aims to enhance the quality of life of the person with a disability by assisting them to achieve their chosen lifestyles and life goals through individualised planning and support coordination.
The case management includes:
- engagement and relationship building;
- information collection and assessment;
- planning and prioritisation of needs;
- allocation, development and negotiation of resources;
- implementation of a plan;
- monitoring of the plan; and
- review of the plan, case closure or reassessment.
Physiotherapists work with the person with the ABI to maximise physical functioning and maintain joint integrity and muscle length. The person usually spends time working with the physiotherapist in the gymnasium, at home and in the community. Physiotherapists may be involved in the rehabilitation process when the person is in hospital and in the community.
They can assess and treat posture, movement, muscle strength, coordination, balance and stamina. Recommendations are made concerning transferring, walking, and fitness. They can provide advice on splints and walking aids, develop a fitness/mobility plan and provide training to family and care staff training. For more information visit the Physiotherapy Association website: www.physiotherapy.asn.au
Social Workers also work with the person with ABI's family and help them to adjust to the individual's injury. They can be involved in legal and financial issues as well as injury claims and insurance. Social workers work with individuals and their families on a range of issues in the hospital and after discharge. They offer support and counselling to adjust to the many changes that can often arise from having had a brain injury. Social workers liaise with community services, government departments and other organisations such as insurance companies and solicitors to ensure the individual is informed of what is going on and their rights are protected.
SW’s work within the principals of social justice, enhancement of quality of life and the development of full potential for each individual, group or community in society. They are able to assist people to deal with the emotional and social results of an ABI/TBI. This can include assisting clients and their families adjusting to changes in their lifestyle, relationships, work and leisure activities. This assistance can be in the form of counselling, direct support, advocacy, advice and referral to other services and agencies. They can provide information and support for families and friends to manage the changes experienced by the person and the impact on relationships. For more information visit: info@ aaswnsw.com.au
Occupational Therapists work with the person with ABI to get them back to doing everyday activities. Occupational therapists look at what the individual was doing prior to their injury and what they will need to do when they leave hospital. The occupational therapist then works with the individual on regaining competence in these activities.
It may be necessary for the individual to use adaptive equipment or make modifications to the home or work place to maximise the individual's independence. The occupational therapist will prescribe this equipment or environmental change. The occupational therapist will work with the individual in the hospital, home, community, workplace, school or educational institution and leisure environments.
The OT will look at how skills may have changed for a person after a traumatic brain injury and then suggests new ways to do things or modified equipment to help a person be independent in that activity. This includes identifying levels of care and support required to complete tasks. Some OT’s will have accreditation to provide driving assessments. Visit the OTNSW website to find out more: www.otnsw.com.au/ot/
Neuropsychologists can assess the impact that a brain injury has had on a person’s cognitive abilities, their strengths and weaknesses e.g. memory and thinking. They can explain what problems these changes have on thinking including decision making, planning and organising etc. They may offer ideas on how to manage these changes.
Neuropsychologists use a number of tests to identify where the individual is having difficulty with their brain function. Areas neuropsychologists examine include attention, memory, speed of information processing, flexibility in thinking, manipulation of information, abstract thinking and general knowledge. This information is fed back to the Team and provides information regarding the extent and severity of the injury and areas where these difficulties may affect daily functioning.
Psychiatrists and Clinical Psychologists
Both psychiatrists and Psychologists work in the area of ABI/TBI, and often work together. There are some significant differences between the two professions in the following areas.
Clinical Psychologists work with the person with ABI on specific areas that limit their ability to get on with everyday life. This may include counselling, developing behaviour management and support programs where the clinical psychologist works with the individual on specific areas of their behaviour. Different areas may be stress management, sleep disturbances, anxiety, depression and anger management.
Psychologists assist people with everyday problems such as understanding and adjusting to their ABI/TBI or better managing their temper and the impact of behaviours by learning strategies to reduce the consequences of change after ABI/TBI. They help people to develop the skills needed to function better and to prevent ongoing problems. Their treatments are based on changing behaviour and emotional responses without medication.
Psychiatrists treat the effects of emotional disturbances on the body and the effects of physical conditions on the mind. They are doctors and can prescribe medication. Some combine medication with other forms of therapy.
Both can provide education to the person, families and others about managing behaviour changes. Visit the Australian Psychological Association website to find out more: www.psychology.org.au/community/about/
Recreation Officers can assist to identify potential leisure and recreation pursuits. They may also provide details of appropriate community resources in relation to sport, leisure options, respite and community living. These services are often required as an alternative to employment for people who are not yet ready for vocational rehabilitation or who do not have vocational goals as a result of injury severity.
Speech pathologists initially work in hospitals to recommend advice on eating, including swallowing and appropriate food consistencies. As recovery occurs they work with the individual on areas of language, expressing themselves, understanding information they are receiving and social skills. Speech pathologists also work with the individual beyond the hospital in the community, in individual and group situations.
Speech Pathologist’s previously called speech therapists they are concerned with the diagnosis management and treatment of individuals who are unable to communicate effectively or who have difficulties with eating and swallowing. This includes assessment and treatment of how a person after an ABI/TBI understands speech, expresses themselves, their reading and writing skills as well as communication with others socially. A Speech Pathologist can assess swallowing and hearing difficulties, trial communication aids and train the person, their staff/family on how to use them. For more information visit: www.speechpathologyaustralia.org.au/ information-for-the-public/
Other Therapeutic Interventions and Assessments
Vocational Rehabilitation and Functional Vocational Assessment:
A functional vocational assessment is required to plan vocational rehabilitation for a return to pre-injury employment, for job seeking, to improve skills for vocational opportunities and achieve employment. This is usually carried out by an occupational therapist as part of a specific referral to a vocational service.
Living Skills Assessment:
This is a comprehensive assessment to review the impact of cognitive and physical changes for self care and equipment needs, physical abilities for functional activities such as transferring and mobility, physical aspects of personal care, safety and security, ability to be left alone and to occupy time, requirements for accessing the community, money handling skills, identification of leisure and recreation options, awareness/ability to organise own time, use of memory aids such as a diary/checklists and meal planning/ preparation. This assessment can be completed by a single therapist (usually Occupational Therapy) or by a multidisciplinary team in the person’s home and community or as part of a residential program in a dedicated unit.
Counselling, family therapy, rehabilitation psychology, medical tests e.g. sleep studies, orthoptist/ophthalmologist, dietician, group therapy programs e.g. ABI/TBI education & information, exercise physiologist, skill based learning e.g. social communication, memory groups, recreation programs, peer support programs.
Residential Care Staff
Residential Care Staff work with individuals in the transitional living units. In the transitional living unit residential care staff are responsible for ensuring the safety of those in the house and the facilitation of the residential rehabilitation program or residential program with a leisure focus. Other carers or support workers may replace residential care staff when they return home or are in permanent independent housing.
4. What is case management?
Why is it so important?
Case Management for people with a disability aims to:
- enhance the quality of life of the person with a disability by assisting them to achieve their chosen lifestyles and life goals through individualised planning and support coordination.
The case management process includes:
- engagement and relationship building;
- information collection and assessment;
- planning and prioritisation of needs;
- allocation, development and negotiation of resources;
- implementation of a plan;
- monitoring of the plan; and
- review of the plan, case closure or reassessment.
Why is case management important?
There are several reasons why case management is especially important for people with serious ABI.
Finding the right service pathway for a person with moderate to severe AB I is complex. One needs to understand each of:
a) The person's injury and their personal journey of recovery and rehabilitation
b) Typical service pathways
c) Typical funding pathways for rehabilitation and support services
Each of these three pathways are complex in themselves. Finding the best pathway for any one person with an ABI is especially complex.
Some people with ABI have cognitive impairments because of their injury that make it difficult for them to manage their rehabilitation process.
Some people with ABI have an episodic need for case management.
5. What services are available?
Health and community services?
With additional $?
Health and community services
People with ABI use health and community services just as people do who do not have an ABI.
People with ABI use:
Community health services
People with ABI can also need additional services to enable them to live as independently as possible in the community.
People with ABI may be able to receive funding for these additional services.
6. What consumer groups are there?
Carers Australia is the national peak body representing Australia’s carers, advocating on behalf of Australia’s carers to influence policies and services at a national level. It works collaboratively with partners and its member organisations, the Network of state and territory Carers Associations, to deliver a range of essential national carer services.
It includes links to State Carer Associations
Brain Injury Australia
Brain Injury Australia is the central clearinghouse of information and gateway to nationwide referral for optimising the social and economic participation of all Australians living with brain injury.
Is has links to Australian Brain Injury Organisations
The Stroke Foundation is a national charity that partners with the community to prevent, treat and beat stroke. We stand alongside stroke survivors and their families, healthcare professionals and researchers. We build community awareness and foster new thinking and innovative treatments. We support survivors on their journey to live the best possible life after stroke.
It has links to State Stroke Associations
Paraplegic and Quadriplegic Association of NSW (ParaQuad NSW)
ParaQuad NSW (Paraplegic and Quadriplegic Association of NSW) is a not-for-profit member-based association that aims to support people with a spinal cord injury to achieve their choices in life.
ParaQuad provides niche services including vital care, accommodation, support and clinical services to people with a spinal cord injury, their families and carers at every stage of life.
Is includes links to associations in Australia and overseas
7. What is the insurance status of the brain injury event?
What was your age when this happened?
Why is this important?
The insurance status and/or age at the injury event will determine what sources of funds you are entitled to.
Many injury events are covered by insurance, for example:
- Workers compensation
- Insurance policies such as disability insurance, public liability insurance.
- Motor vehicle accident insurance
If the injury event is covered by insurance you may be entitled to insurance payouts from the relevant insurance.
Irrespective of these insurance payouts everyone is covered by the National Disability Insurance Scheme (NDIS) and/or Commonwealth Governments Aged Care Programs including the Commonwealth Home Support Program.
If the age at injury is less than 65 the NDIS applies. If the age at injury is 65 or more the Aged Care Programs apply.
The payments and services provided through the NDIS and Aged Care Programs may be adjusted where the injury event is specifically insured and there are insurance payouts to the person with the ABI.
8. What funding agencies fund services?
What are their eligibility criteria?
What do they base the $ on?
The National Disability Insurance Scheme (NDIS) provides support for Australians with disability, their families and carers.
As an insurance scheme, the NDIS takes a lifetime approach, investing in people with disability early to improve their outcomes later in life.
The NDIS ensures that if someone is born with or acquires a permanent and significant disability they will get the support they need.
The NDIS supports people with disability to build skills and capability so they can participate in the community and employment.
To be eligible to access the NDIS you must
1. Live in Australia and be:
- an Australian citizen OR
- a permanent resident OR
- hold a Protected Special Category Visa
2. Age under 65 years at the time of acquiring the disability
3. Usually need support from a person or equipment to do everyday things for yourself because of an impairment or condition that is likely to be permanent?
E.g. Do you usually need support from a person or assistive equipment so you can:
- understand and be understood by other people?
- make and keep friends and cope with feelings and emotions?
- understand, remember and learn new things?
- get out of bed and move around the home and outside the home?
- take a bath or shower, dress and eat?
- do daily jobs, handle money and make decisions?
4. Need some supports now to reduce your support needs in the future?
To meet the NDIS early intervention rules, you need to:
- have an impairment or condition that is likely to be permanent (lifelong); or
- be a child under 6 years of age with a developmental delay and the delay means you usually need more help with your self-care, communication, learning or motor skills than another child of the same age.
Early intervention supports provided by the NDIS are those not provided by any other services such as health and education.
Would early intervention supports:
- reduce the impact of your impairment or condition or developmental delay?
- stop the impact of your impairment or condition from getting worse?
- strengthen your informal supports, such as helping a carer to keep supporting you?
$ BASED ON
The NDIA makes decisions based on the National Disability Insurance Scheme Act 2013 (NDIS Act) and the rules made under the NDIS Act. The operational guidelines also provide practical guidance for decision makers.
When the NDIA makes decisions about which supports would be reasonable and necessary for a particular participant, we refer to the particular operational guideline that relates to each specific support. In order to be considered reasonable and necessary, a support must:
- be related to the participant's disability
- not include day-to-day living costs that are not related to a participant's disability support needs
- represent value for money
- be likely to be effective and beneficial to the participant, and
- take into account informal supports given to participants by families, carers, networks, and the community.
Australian Government funded aged care services
There are Australian Government aged care programs:
- To support people living independently in their homes and
- To provide alternatives where they are unable to continue living independently in their own homes.
Eligibility criteria include:
- older person (usually 65+ or 50+ for Aboriginal and Torres Strait Islander people)
- finding it harder to do the things you used to do.
A face-to-face assessment of your care needs is required to determine if you are eligible.
Everyone who has an assessment through My Aged Care and is found to need services, is eligible to access services that: may be partly or fully funded by the Australian Government; and are regulated by the Australian Government.
If you need ongoing help with day-to-day tasks or health care, an aged care home lets you live in a supported environment where help is available 24 hours a day. The Australian Government contributes to the cost of aged care services. You’re expected to contribute if you can afford to. Costs vary for different types of care and different service providers. There are no standard costs for aged care services. How much you pay depends on: your financial situation the number and types of services you receive the service provider’s fees.
NSW - icare
To be covered by workers insurance following a workplace injury or illness, you will need to provide medical evidence that indicates it was sustained as a result of your employment.
There are different types of claims a worker can make following a workplace incident. Different types of claims have different eligibility criteria. For example if you are claiming lump sum compensation for permanent impairment arising out of a psychological injury you need to be assessed as having a permanent impairment of 15% or more. However if you were claiming lump sum compensation for a physical injury you need to be assessed as having a permanent impairment of more than 10%. Claims for injuries that occurred during a work journey or on a work break have different eligibility criteria as well. All other workplace injury claims will be assessed on a case by case basis.
Private insurance companies
Eligibility criteria determined by conditions in the insurance policy.
There are many different types of insurance policies and conditions. Polices can include for example public liability, disability insurance, income protection insurance, etc
NSW - Lifetime care
The lifetime care pays for treatment, rehabilitation and care for people who have been severely injured in a motor accident in NSW.
lifetime care is a no-fault scheme. This means support is provided regardless of who was at fault in the accident, as long as you meet our eligibility criteria for both your motor accident and your injury.
Eligibility criteria include:
- You were injured in a motor accident in NSW On or after 1 October 2006 (for children under 16) or on or after 1 October 2007 (for adults)
- Your injury was caused by the motor accident
- The type and severity of your motor accident injury meet the injury criteria Each application is assessed against specific criteria outlined in the Lifetime Care and Support guidelines.
Each application is assessed against specific criteria outlined in the icare lifetime care guidelines.
Severe injuries that may be eligible for the Scheme include: Spinal cord injury, brain injury, amputations, burns, permanent blindness
EnableNSW provides equipment and services to people in NSW with chronic health conditions or disability to assist them with mobility, communication and self-care.
Enable also provides financial assistance for people who have to travel significant distances to access specialist medical treatment which is not available locally.
As part of HealthShare NSW, EnableNSW is responsible for the administration of NSW Health disability support and other assistance programs.
The NDIS is a new way of providing funding for care and other supports (such as equipment) for eligible people. Equipment supports may include continence products, wheelchairs, beds and prosthetic limbs.
In NSW, funding for some of these items currently provided through EnableNSW will move to the NDIS.
EnableNSW will continue to provide assistance for people 65 years of age and over or not eligible for the NDIS. Many of EnableNSW's services, including the funding of respiratory consumables and equipment (such as oxygen concentrators), will continue to be available to people of all ages.
9. How are funded services managed?
Managed by service providers
10. Getting the right pathway…
What questions to ask?
Life before and after the injury
- What was the person’s life like before the injury?
- What was the injury - and the impairments and impacts arising?
- What skills does the person need to re-learn to be as independent as possible?
- What supports do they need to be as independent as possible?
Gaols and service pathway to achieve goals
- What are the person’s goals now?
- What is the service pathway that in principle will achieve the goals?
Funding for services and agencies involved
- What is the insurance status of the injury and age at injury?
- What agencies are involved given the insurance status and age at injury?
- For the agencies involved what are the eligibility criteria?
- For the agencies involved what will funding be based on?
- For the agencies involved who provides services?
Managing services and their quality
- How are services managed?
- Are the services person centred?
- Are the services goal directed?
- Are the services building independence?
- Are the services grounded in the relevant principles and standards (e.g. Disability Standards, Attendant care standards, etc.
11. What are key ingredients for the best possible pathway?
Person centred, goal directed, building independence
grounded in principles and standards.
You are an equal partner in planning, developing and accessing services to appropriately meet your needs.
A person centred approach puts you and your family at the heart of all decisions. It aims to:
- Be client focused,
- Promote independence and autonomy,
- Provide choice and control and
- Be based on a philosophy of collaboration and teamwork.
- It takes into account your needs and views and builds relationships with your family members.
A person centred approach gives people:
- valued roles
- participation and belonging in the community
- freely given relationships
- greater authority over decisions about the way they live
- genuine partnership between the service, themselves and/or their family and allies
- individualised and personalised support arrangements.
Person-centred approaches require that organisations:
- have a committed leadership that actively instills the vision of a person-centred approach at all levels
- have a culture that is open to continual learning about how to implement a person-centred approach
- consciously hold positive beliefs about people with a disability and their potential
- develop equal and ethical partnerships with people with a disability and their families
- work with people to individually meet each person’s needs so that they can be in valued roles in valued settings
- develop appropriate organisational structures and processes
Goals are what the client wants to achieve.
Goals belong to you, not to workers, clinicians or service providers.
Rehabilitation programs exist so that you can achieve your goals. Rehabilitation goals typically focus on improvement.
Clients have life goals after rehabilitation – including maintain goals and prevent deterioration.
Attendant care, when required, is part of achieving your goals.
Benefits of setting goals
Setting client goals:
Helps you motivate yourself – i.e. it is easier to work towards achieving your goals when those goals are explicit and you are clear about what you are wanting to achieve.
Makes it clear to everyone what the you are wanting to achieve.
Makes it easier for everyone working with you to work together as a team and coordinate their efforts to achieving the goals.
Makes it easier for everyone to see how well things are working: Are the goals being achieved?
Individual service plans
Individual service plans are needed so that the steps needed to achieve the gaols are documented and everyone involved is working together.
Individual service plans:
- Start with your goals
- Establish the steps needed to achieve your goals
- And then design the actions and services needed to achieve the steps.
To be useful goals must describe what's to be achieved
Useful goals describe what the client wants to achieve, not what the client or service provider is supposed to do. The program describes what is to be done.
Jill’s goal: To be able to care for her child independently.
Jill’s program: Jill does her home exercise program and attends occupational therapy sessions.
She does this because she wants to be able to care for her child independently.
Sometimes goals do not reflect what the client wants to achieve in their life. For example if Jill’s goal were written as: To do the home exercise program each day and attends occupational therapy each week this would not be an appropriate
Good attendant care is:
Where the person is at the centre of planning and delivery of services
Enabling life in and with community
Sees the person as part of a social network which may include family, friends, neighbourhood & community
Goal directed (to maximise independence)
During rehabilitation – improvement focussed to achieve new goals
Life going on – to maintain goals (and prevent deterioration)
Based on human rights
For example respect for the dignity and independence of persons, non-discrimination, full and effective participation and inclusion in society.
Based on quality management principles
For example focussing on outcomes for people who use services, making evidence based decisions and encouraging continuous improvement.
These principles are supported by standards.
National Standards for Disability Services
In Australia, Attendant Care services are required to meet the National Standards for Disability Services.
The Attendant Care Industry Standard
The peak body for Attendant Care Services, the Attendant Care Industry Association also has a set of standards its members adopt: the Attendant Care Industry Standard. In NSW these standards are also recognised by the Lifetime Care Authority and Ageing Disability and Home Care (ADHC) as standards service providers should meet.